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Ingber RS. Iliopsoas trigger point dry needling and therapeutic stretching in the treatment of a series of six consecutive patients presenting with acute lumbar radiculitis and foot drop. J Bodyw Mov Ther 2023; 36:1-4. [PMID: 37949544 DOI: 10.1016/j.jbmt.2023.04.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 08/12/2021] [Accepted: 04/15/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To evaluate the clinical results, number of treatments administered and the cost of care of a series of six consecutive patients presenting with acute lumbar radiculitis and a foot drop treated with iliopsoas myofascial treatments. METHOD A retrospective chart review of the results of iliopsoas myofascial treatments for acute lumbar radiculitis in six consecutive patients presenting with acute sciatic pain and ipsilateral foot drop. RESULTS Five of six (83%) patients with acute lumbar radiculitis and foot drop responded without need for surgical decompression. In responders, heel walk returned in 2, 3, 10, 13 and 32 weeks after initiating treatment. The patients received an average of 6.7 trigger point dry needling treatments (range 3-14) and 9.5 physical therapy sessions (range 3-16). The average cost of the medical care, based upon the rate of $125 for trigger points and $75 for physical therapy, was $1691.66 (range $693.75-2712.50). CONCLUSIONS Iliopsoas myofascial treatments achieved an acceptable, risk-free, relatively inexpensive method of management in the non-surgical care of these six patients presenting with severe, acute lumbar radiculitis.
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Cho S, Lim YC, Kim EJ, Park Y, Ha IH, Lee YS, Lee YJ. Analysis of Conservative Treatment Trends for Lumbar Disc Herniation with Radiculopathy in Korea: A Population-Based Cross-Sectional Study. Healthcare (Basel) 2023; 11:2353. [PMID: 37628549 PMCID: PMC10454101 DOI: 10.3390/healthcare11162353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 08/27/2023] Open
Abstract
This study aimed to analyze the trends in conservative treatment and associated medical costs for lumbar intervertebral disc disorders with radiculopathy in Korea. This population-based cross-sectional study included patients aged ≥ 20 years with at least one "intervertebral disc disorder with radiculopathy" claim (Korean Standard Classification of Diseases (KCD)-7 code: M511) who sought treatment from tertiary, general, or Korean Medicine hospitals or clinics between 2010 and 2019 and whose data were extracted from the Korean Health Insurance Review and Assessment Service National Patients Sample database. Intervention frequency, ratio, and medical costs, including medication, were analyzed. The number of patients with lumbar intervertebral disc disorders and radiculopathy undergoing conservative treatment increased by >30%, and medical costs increased from USD 3,342,907 to USD 5,600,456 during the 10-year period. The non-surgical treatments mainly used were medication and physiotherapy, and the most commonly prescribed medication was non-opioid analgesics. Meanwhile, the number of patients who used nerve plexus and root and ganglion nerve blocks showed the most significant increase. In conclusion, the number of patients with radiculopathy who received nerve blocks, particularly nerve plexus and root and ganglion nerve blocks, and related expenditure increased, implying a gradual shift in medical decisions from systemic pain reduction to specific and targeted pain treatments. Future studies and clinical practice guidelines may require further inspection of real-world practice to advise optimal treatment choices for an effective treatment plan.
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Affiliation(s)
- Sohyun Cho
- Jaseng Korean Medicine Hospital, Seoul 06110, Republic of Korea;
| | - Yu-Cheol Lim
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul 06110, Republic of Korea; (Y.-C.L.); (I.-H.H.)
| | - Eun-Jung Kim
- Department of Acupuncture & Moxibustion, College of Korean Medicine, Dongguk University Bundang Oriental Hospital, Seongnam 13601, Republic of Korea;
| | - Yeoncheol Park
- Department of Acupuncture & Moxibustion, Kyung Hee University at Gangdong, 892 Dongnam-ro, Gangdonggu, Seoul 05278, Republic of Korea;
| | - In-Hyuk Ha
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul 06110, Republic of Korea; (Y.-C.L.); (I.-H.H.)
| | - Ye-Seul Lee
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul 06110, Republic of Korea; (Y.-C.L.); (I.-H.H.)
| | - Yoon Jae Lee
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul 06110, Republic of Korea; (Y.-C.L.); (I.-H.H.)
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3
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Sayed D, Grider J, Strand N, Hagedorn JM, Falowski S, Lam CM, Tieppo Francio V, Beall DP, Tomycz ND, Davanzo JR, Aiyer R, Lee DW, Kalia H, Sheen S, Malinowski MN, Verdolin M, Vodapally S, Carayannopoulos A, Jain S, Azeem N, Tolba R, Chang Chien GC, Ghosh P, Mazzola AJ, Amirdelfan K, Chakravarthy K, Petersen E, Schatman ME, Deer T. The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain. J Pain Res 2022; 15:3729-3832. [PMID: 36510616 PMCID: PMC9739111 DOI: 10.2147/jpr.s386879] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety. Objective The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders. Methods The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented. Results After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain. Conclusion The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.
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Affiliation(s)
- Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA,Correspondence: Dawood Sayed, The University of Kansas Health System, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA, Tel +1 913-588-5521, Email
| | - Jay Grider
- University of Kentucky, Lexington, KY, USA
| | - Natalie Strand
- Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Steven Falowski
- Functional Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Christopher M Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Nestor D Tomycz
- AHN Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | - Rohit Aiyer
- Interventional Pain Management and Pain Psychiatry, Henry Ford Health System, Detroit, MI, USA
| | - David W Lee
- Physical Medicine & Rehabilitation and Pain Medicine, Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA
| | - Hemant Kalia
- Rochester Regional Health System, Rochester, NY, USA,Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Soun Sheen
- Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Mark N Malinowski
- Adena Spine Center, Adena Health System, Chillicothe, OH, USA,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Michael Verdolin
- Anesthesiology and Pain Medicine, Pain Consultants of San Diego, San Diego, CA, USA
| | - Shashank Vodapally
- Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI, USA
| | - Alexios Carayannopoulos
- Department of Physical Medicine and Rehabilitation, Rhode Island Hospital, Newport Hospital, Lifespan Physician Group, Providence, RI, USA,Comprehensive Spine Center at Rhode Island Hospital, Newport Hospital, Providence, RI, USA,Neurosurgery, Brown University, Providence, RI, USA
| | - Sameer Jain
- Interventional Pain Management, Pain Treatment Centers of America, Little Rock, AR, USA
| | - Nomen Azeem
- Department of Neurology, University of South Florida, Tampa, FL, USA,Florida Spine & Pain Specialists, Riverview, FL, USA
| | - Reda Tolba
- Pain Management, Cleveland Clinic, Abu Dhabi, United Arab Emirates,Anesthesiology, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - George C Chang Chien
- Pain Management, Ventura County Medical Center, Ventura, CA, USA,Center for Regenerative Medicine, University Southern California, Los Angeles, CA, USA
| | | | | | | | - Krishnan Chakravarthy
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA,Va San Diego Healthcare, San Diego, CA, USA
| | - Erika Petersen
- Department of Neurosurgery, University of Arkansas for Medical Science, Little Rock, AR, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA,Department of Population Health - Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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Kaiser M, Brambrink S, Benditz A, Achenbach L, Gehentges M, König MA. Increase in Lower Limb Strength after Multimodal Pain Management in Patients with Low Back Pain. Medicina (B Aires) 2022; 58:medicina58070837. [PMID: 35888556 PMCID: PMC9319983 DOI: 10.3390/medicina58070837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/07/2022] [Accepted: 06/19/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: The aim of the present study was to evaluate the efficacy of a multimodal pain therapy (MPM) regarding the objective parameter muscle strength of segment-dependent lower limb muscle groups before and after such a treatment. Materials and Methods: 52 patients with a history of low back pain and/or leg pain received standardized multimodal pain management. Strength of segment indicating lower limb muscles were assessed for each patient before and after ten days of treatment by handheld dynamometry. Results: Overall strength increased significantly from 23.6 kg ± 6.6 prior to treatment to 25.4 ± 7.3 after treatment, p ≤ 0.001. All muscle groups significantly increased in strength with exception of great toe extensors. Conclusions: Despite lower basic strength values at the beginning of treatment, all investigated muscle groups, except for the great toe extensors, showed a significant increase of overall strength after completion of the multimodal pain management concept. Increased overall strength could help with avoiding further need of medical care by supporting patients’ autonomy in daily life activities, as well as maintaining working abilities. Thus, our study is the first to show a significant positive influence on lower limb strength in patients with low back pain after a conservative MPM program.
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Affiliation(s)
- Moritz Kaiser
- Department of Orthopedic Surgery, Regensburg University Medical Center, 93077 Bad Abbach, Germany; (S.B.); (M.G.); (M.A.K.)
- Correspondence: (M.K.); (A.B.)
| | - Sara Brambrink
- Department of Orthopedic Surgery, Regensburg University Medical Center, 93077 Bad Abbach, Germany; (S.B.); (M.G.); (M.A.K.)
| | - Achim Benditz
- Department of Orthopedic Surgery, Regensburg University Medical Center, 93077 Bad Abbach, Germany; (S.B.); (M.G.); (M.A.K.)
- Correspondence: (M.K.); (A.B.)
| | - Leonard Achenbach
- Department of Orthopedic Surgery, König-Ludwig-Haus, Julius-Maximilians-University Würzburg, 97074 Würzburg, Germany;
| | - Matthias Gehentges
- Department of Orthopedic Surgery, Regensburg University Medical Center, 93077 Bad Abbach, Germany; (S.B.); (M.G.); (M.A.K.)
| | - Matthias Alexander König
- Department of Orthopedic Surgery, Regensburg University Medical Center, 93077 Bad Abbach, Germany; (S.B.); (M.G.); (M.A.K.)
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Carassiti M, Pascarella G, Strumia A, Russo F, Papalia GF, Cataldo R, Gargano F, Costa F, Pierri M, De Tommasi F, Massaroni C, Schena E, Agrò FE. Epidural Steroid Injections for Low Back Pain: A Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:ijerph19010231. [PMID: 35010492 PMCID: PMC8744824 DOI: 10.3390/ijerph19010231] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/19/2021] [Accepted: 12/22/2021] [Indexed: 05/03/2023]
Abstract
Low back pain represents a significant socioeconomic burden. Several nonsurgical medical treatments have been proposed for the treatment of this disabling condition. Epidural steroid injections (ESIs) are commonly used to treat lumbosacral radicular pain and to avoid surgery. Even though it is still not clear which type of conservative intervention is superior, several studies have proved that ESIs are able to increase patients' quality of life, relieve lumbosacral radicular pain and finally, reduce or delay more invasive interventions, such as spinal surgery. The aim of this narrative review is to analyze the mechanism of action of ESIs in patients affected by low back pain and investigate their current application in treating this widespread pathology.
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Affiliation(s)
- Massimiliano Carassiti
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
- Correspondence:
| | - Giuseppe Pascarella
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Alessandro Strumia
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Fabrizio Russo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.R.); (G.F.P.)
| | - Giuseppe Francesco Papalia
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.R.); (G.F.P.)
| | - Rita Cataldo
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Francesca Gargano
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Fabio Costa
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Michelangelo Pierri
- Integrated Sleep Surgery Team UCBM, Unit of Otolaryngology, Integrated Therapies in Otolaryngology, Campus Bio-Medico University of Rome, 00128 Rome, Italy;
| | - Francesca De Tommasi
- Unit of Measurements and Biomedical Instrumentation, Department of Engineering, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.D.T.); (C.M.); (E.S.)
| | - Carlo Massaroni
- Unit of Measurements and Biomedical Instrumentation, Department of Engineering, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.D.T.); (C.M.); (E.S.)
| | - Emiliano Schena
- Unit of Measurements and Biomedical Instrumentation, Department of Engineering, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.D.T.); (C.M.); (E.S.)
| | - Felice Eugenio Agrò
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
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6
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de Bruijn TM, de Groot IB, Miedema HS, Haumann J, Ostelo RW. Clinical Relevance of Epidural Steroid Injections on Lumbosacral Radicular Syndrome-related Synptoms: Systematic Review and Meta-Analysis. Clin J Pain 2021; 37:524-537. [PMID: 33859113 PMCID: PMC8162229 DOI: 10.1097/ajp.0000000000000943] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Epidural steroid injections (ESIs) can be used to reduce lumbosacral radicular syndrome (LRS) related pain. The clinical relevance of ESIs are currently unknown. This systematic review and meta-analyses aims to assess whether ESIs are clinically relevant for patients with LRS. MATERIALS AND METHODS Comprehensive literature searches for randomized controlled trials regarding steroid injections for LRS were conducted in PudMed, EMBASE, CINAHL, and CENTRAL from their inception to September 2018 (December 2019 for PubMed). For each homogenous comparison, the outcomes function, pain intensity and health-related quality of life at different follow-up intervals were pooled separately. The GRADE approach was used to determine the overall certainty of the evidence. RESULTS Seventeen studies were included. Two different homogenous comparisons were identified for which the randomized controlled trials could be pooled. In 36 of the 40 analyses no clinically relevant effect was found. The certainty of evidence varied between very low to high. Four analyses found a clinically relevant effect, all on pain intensity and health-related quality of life, but the certainty of the evidence was either low or very low. Two of the 33 subgroup analyses showed a clinically relevant effect. However, according to the GRADE approach the certainty of these findings are low to very low. DISCUSSION On the basis of the analyses we conclude there is insufficient evidence that ESIs for patients with LRS are clinically relevant at any follow-up moment. High-quality studies utilizing a predefined clinical success are necessary to identify potential clinically relevant effects of ESIs. Until the results of these studies are available, there is reason to consider whether the current daily practice of ESIs for patients with LRS should continue.
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Affiliation(s)
- Thomas M. de Bruijn
- Department Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam
- National Health Care Institute, Diemen
| | | | - Harald S. Miedema
- National Health Care Institute, Diemen
- Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
| | | | - Raymond W.J.G. Ostelo
- Department Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam
- Department of Epidemiology and Biostatistics, Amsterdam UMC (Location VUmc) and Amsterdam Movement Sciences, Amsterdam
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Hirase T, Hirase J, Ling J, Kuo PH, Hernandez GA, Giwa K, Marco R. Duloxetine for the Treatment of Chronic Low Back Pain: A Systematic Review of Randomized Placebo-Controlled Trials. Cureus 2021; 13:e15169. [PMID: 34046287 PMCID: PMC8140818 DOI: 10.7759/cureus.15169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
This systematic review determines the efficacy and safety of duloxetine for chronic low back pain (CLBP). We queried the PubMed, SCOPUS, and Ovid MEDLINE databases. All level I and II randomized controlled studies published in the English language investigating the efficacy of duloxetine for chronic low back pain were included. Five studies (832 duloxetine-treated patients, 667 placebo-treated patients, and 41 duloxetine and placebo crossover analysis patients) were analyzed. One study was level I evidence and four studies were level II evidence. All five studies reported statistically significant improvements in more than one back-pain-specific clinical outcome score with duloxetine versus placebo. Four studies found that duloxetine 60 mg daily leads to one or more statistically significant improvements versus placebo in Brief Pain Inventory Severity (BPI-S) scores. All five studies found no significant difference in serious adverse events (AEs) between the duloxetine and placebo groups. One study found a higher rate of total AEs among the duloxetine 120 mg group versus the placebo group; however, the same study did not find a significant difference in total AEs among duloxetine 20 mg and 60 mg groups versus placebo. Duloxetine is a safe and effective first-line option for the treatment of CLBP. Current studies demonstrate that 60 mg taken once daily has the highest efficacy for reducing pain and disability while minimizing minor adverse effects. Further randomized controlled trials with long-term follow-up are necessary to determine its long-term effects.
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Affiliation(s)
- Takashi Hirase
- Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, USA
| | | | - Jeremiah Ling
- Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, USA
| | - Peggy H Kuo
- Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, USA
| | | | - Kayode Giwa
- Psychiatry, Houston Methodist Hospital, Houston, USA
| | - Rex Marco
- Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, USA
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8
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Ko S, Jun C, Lee JJ, Nam J. Comparison of the effects of corticosteroid and hyaluronic acid-carboxymethylcellulose solution on selective nerve root block for lumbar radiculopathy: A prospective, double-blind, randomized controlled clinical trial. Pain Pract 2021; 21:785-793. [PMID: 33872462 DOI: 10.1111/papr.13018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/03/2021] [Accepted: 04/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Selective nerve root block (SNRB) was shown to effectively control radiating pain and reduce the need for surgical intervention. However, repetitive injections may trigger corticosteroid-induced side effects (hypercorticism, hyperglycemia, or fluid retention). This study aims to compare the potency of hyaluronic acid-carboxymethylcellulose (HA-CMC) solution versus that of corticosteroids regarding lower leg radiating pain (LLRP) improvement and functional outcome. METHODS Among 128 patients, 44 patients who complain about having LLRP due to lumbar spinal stenosis and do not have neurological symptoms requiring surgery were enrolled for this study. Group A with 22 patients injected with cocktail A (local anesthetics and corticosteroid) and group B with 22 patients injected with cocktail B (local anesthetics and HA-CMC). Outcome measures were the visual analog scale (VAS), Oswestry Disability Index (ODI), and short form-36 (SF-36). All patients were asked to fill in the questionnaires during the follow-up assessment period at 3 days, 7 days, 2 weeks, 6 weeks, and 12 weeks. RESULTS In all time periods, there were no statistical differences between the two groups for VAS scores and VAS improvement over time, ODI scores and ODI improvement over time, and SF-36 PCS scores and SF-36 mental component score scores. Additionally, the 95% confidence interval of the difference in VAS score improvement between the 2 groups in all time periods was within VAS 5.0, which is the minimum clinically relevant difference. CONCLUSIONS Considering the adverse effects of corticosteroids, and the similar LLRP improvements, functional outcome, and quality of life, the HA-CMC solution may be an alternative option to corticosteroid in SNRB.
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Affiliation(s)
- Sangbong Ko
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Daegu City, Korea
| | - ChungMu Jun
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Daegu City, Korea
| | - Jae Jun Lee
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Daegu City, Korea
| | - Junho Nam
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Daegu City, Korea
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9
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Ling JF, Wininger AE, Hirase T. Platelet-Rich Plasma Versus Corticosteroid Injection for Lumbar Spondylosis and Sacroiliac Arthropathy: A Systematic Review of Comparative Studies. Cureus 2021; 13:e14062. [PMID: 33898145 PMCID: PMC8061754 DOI: 10.7759/cureus.14062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 12/23/2022] Open
Abstract
This systematic review compares clinical outcomes between platelet-rich plasma (PRP) and corticosteroid injections for the treatment of lumbar spondylosis and sacroiliac arthropathy. A systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) and performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the Pubmed, SCOPUS, and Ovid MEDLINE databases. All level I-III evidence comparative studies published in the English language investigating the clinical outcomes between PRP and corticosteroid injections for the treatment of lumbar spondylosis and sacroiliac arthropathy were included. Five studies (242 patients, 114 PRP, 128 corticosteroid) were analyzed. One randomized study was level I evidence, two randomized studies were level II, and two non-randomized studies were level III. Final follow-up ranged from six weeks to six months. Four studies found that both PRP and corticosteroid treatment led to a statistically significant reduction in the visual analog scale (VAS). One found that only the PRP group led to a statistically significant reduction in VAS. Three studies found more significant improvements in one or more clinical outcome scores among PRP patients as compared with corticosteroid patients at the three- to six-month follow-up. Two studies found no difference in outcome score improvements between the two groups at six- to 12-week follow-up. There were no reports of major complications. There were no significant differences in minor complication rates between the two groups. In conclusion, both PRP and corticosteroid injections are safe and effective options for the treatment of lumbar spondylosis and sacroiliac arthropathy. There is some evidence that PRP injection is a more effective option at long-term follow-up compared with corticosteroid injection. Further randomized controlled trials with longer-term follow-up are necessary to compare its long-term efficacy.
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Affiliation(s)
- Jeremiah F Ling
- Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, USA
| | - Austin E Wininger
- Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, USA
| | - Takashi Hirase
- Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, USA
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10
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Oliveira CB, Maher CG, Ferreira ML, Hancock MJ, Oliveira VC, McLachlan AJ, Koes BW, Ferreira PH, Cohen SP, Pinto RZ. Epidural Corticosteroid Injections for Sciatica: An Abridged Cochrane Systematic Review and Meta-Analysis. Spine (Phila Pa 1976) 2020; 45:E1405-E1415. [PMID: 32890301 DOI: 10.1097/brs.0000000000003651] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic with meta-analysis OBJECTIVES.: The aim of this study was to investigate the efficacy and safety of epidural corticosteroid injections compared with placebo injection in reducing leg pain and disability in patients with sciatica. SUMMARY OF BACKGROUND DATA Conservative treatments, including pharmacological and nonpharmacological treatments, are typically the first treatment options for sciatica but the evidence to support their use is limited. The overall quality of evidence found by previous systematic reviews varies between moderate and high, which suggests that future trials may change the conclusions. New placebo-controlled randomized trials have been published recently which highlights the importance of an updated systematic review. METHODS The searches were performed without language restrictions in the following databases from 2012 to 25 September 2019: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PubMed, Embase, CINAHL, PsycINFO, International Pharmaceutical Abstracts, and trial registers. We included placebo-controlled randomized trials investigating epidural corticosteroid injections in patients with sciatica. The primary outcomes were leg pain intensity and disability. The secondary outcomes were adverse events, overall pain, and back pain intensity. We grouped similar trials according to outcome measures and their respective follow-up time points. Short-term follow-up (>2 weeks but ≤3 months) was considered the primary follow-up time point due to the expected mechanism of action of epidural corticosteroid injection. Weighted mean differences (MDs) and risk ratios (RRs) with their respective 95% confidence intervals (CIs) were estimated. We assessed the overall quality of evidence using the GRADE approach and conducted the analyses using random effects. RESULTS We included 25 clinical trials (from 29 publications) providing data for a total of 2470 participants with sciatica, an increase of six trials when compared to the previous review. Epidural corticosteroid injections were probably more effective than placebo in reducing short-term leg pain (MD -4.93, 95% CI -8.77 to -1.09 on a 0-100 scale), short-term disability (MD -4.18, 95% CI: -6.04 to -2.17 on a 0-100 scale) and may be slightly more effective in reducing short-term overall pain (MD -9.35, 95% CI -14.05 to -4.65 on a 0-100 scale). There were mostly minor adverse events (i.e., without hospitalization) after epidural corticosteroid injections and placebo injections without difference between groups (RR 1.14, 95% CI: 0.91-1.42). The quality of evidence was at best moderate mostly due to problems with trial design and inconsistency. CONCLUSION A review of 25 placebo-controlled trials provides moderate-quality evidence that epidural corticosteroid injections are effective, although the effects are small and short-term. There is uncertainty on safety due to very low-quality evidence. LEVEL OF EVIDENCE 1.
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Affiliation(s)
- Crystian B Oliveira
- Department of Physiotherapy, São Paulo State University, Presidente Prudente, Brazil
| | | | - Manuela L Ferreira
- Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Mark J Hancock
- Discipline of Physiotherapy, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Vinicius Cunha Oliveira
- Department of Physiotherapy, Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM), Diamantina, Brazil
| | | | - Bart W Koes
- Department of General Practice, Erasmus Medical Center, Rotterdam, Netherlands.,Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
| | - Paulo H Ferreira
- Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | - Steven P Cohen
- Blaustein Pain Treatment Center, Department of Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rafael Z Pinto
- Department of Physiotherapy, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
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Yang S, Kim W, Kong HH, Do KH, Choi KH. Epidural steroid injection versus conservative treatment for patients with lumbosacral radicular pain: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2020; 99:e21283. [PMID: 32791709 PMCID: PMC7386972 DOI: 10.1097/md.0000000000021283] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 05/06/2020] [Accepted: 06/15/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Previous systemic reviews have examined the efficacy of individual therapeutic agents, but which type of treatment is superior to another has not been pooled or analyzed. The objective of the current study was to compare the clinical effectiveness of epidural steroid injection (ESI) versus conservative treatment for patients with lumbosacral radicular pain. METHODS A systematic search was conducted with MEDLINE, EMBASE, and CENTRAL databases with a double-extraction technique for relevant studies published between 2000 and January 10, 2019. The randomized controlled trials which directly compared the efficacy of ESI with conservative treatment in patients with lumbosacral radicular pain were included. Outcomes included visual analog scale, numeric rating scale, Oswetry disability index, or successful events. Two reviewers extracted data and evaluated the methodological quality of papers using the Cochrane Collaboration Handbook. A meta-analysis was performed using Revman 5.2 software. The heterogeneity of the meta-analysis was also assessed. RESULTS Of 1071 titles initially identified, 6 randomized controlled trials (249 patients with ESI and 241 patients with conservative treatment) were identified and included in this meta-analysis. The outcome of the pooled analysis showed that ESI was beneficial for pain relief at short-term and intermediate-term follow-up when compared with conservative treatment, but this effect was not maintained at long-term follow-up. Successful event rates were significantly higher in patients who received ESI than in patients who received conservative treatment. There were no statistically significant differences in functional improvement after ESI and conservative treatment at short-term and intermediate-term follow-up. The limitations of this meta-analysis resulted from the variation in types of interventions and small sample size. CONCLUSIONS According to the results of this meta-analysis, the use of ESI is more effective for alleviating lumbosacral radicular pain than conservative treatments in terms of short-term and intermediate-term. Patients also reported more successful outcomes after receiving ESI when compared to conservative treatment. However, this effect was not maintained at long-term follow-up. This meta-analysis will help guide clinicians in making decisions for the treatment of patients with lumbosacral radicular pain, including the use of ESI, particularly in the management of pain at short-term.
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Affiliation(s)
- Seoyon Yang
- Department of Rehabilitation Medicine, Ewha Womans University Seoul Hospital, Ewha Womans University
| | - Won Kim
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine
| | - Hyun Ho Kong
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine
| | - Kyung Hee Do
- Department of Rehabilitation Medicine, Veterans Health Service Medical Center, Seoul, Republic of Korea
| | - Kyoung Hyo Choi
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine
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Oliveira CB, Maher CG, Ferreira ML, Hancock MJ, Oliveira VC, McLachlan AJ, Koes BW, Ferreira PH, Cohen SP, Pinto RZ. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database Syst Rev 2020; 4:CD013577. [PMID: 32271952 PMCID: PMC7145384 DOI: 10.1002/14651858.cd013577] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Lumbosacral radicular pain (commonly called sciatica) is a syndrome involving patients who report radiating leg pain. Epidural corticosteroid injections deliver a corticosteroid dose into the epidural space, with the aim of reducing the local inflammatory process and, consequently, relieving the symptoms of lumbosacral radicular pain. This Cochrane Review is an update of a review published in Annals of Internal Medicine in 2012. Some placebo-controlled trials have been published recently, which highlights the importance of updating the previous review. OBJECTIVES To investigate the efficacy and safety of epidural corticosteroid injections compared with placebo injection on pain and disability in patients with lumbosacral radicular pain. SEARCH METHODS We searched the following databases without language limitations up to 25 September 2019: Cochrane Back and Neck group trial register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, International Pharmaceutical Abstracts, and two trial registers. We also performed citation tracking of included studies and relevant systematic reviews in the field. SELECTION CRITERIA We included studies that compared epidural corticosteroid injections of any corticosteroid drug to placebo injections in patients with lumbosacral radicular pain. We accepted all three anatomical approaches (caudal, interlaminar, and transforaminal) to delivering corticosteroids into the epidural space. We considered trials that included a placebo treatment as delivery of an inert substance (i.e. one with no pharmacologic activity), an innocuous substance (e.g. normal saline solution), or a pharmacologically active substance but not one considered to provide sustained benefit (e.g. local anaesthetic), either into the epidural space (i.e. to mimic epidural corticosteroid injection) or adjacent spinal tissue (i.e. subcutaneous, intramuscular, or interspinous tissue). We also included trials in which a local anaesthetic with a short duration of action was used as a placebo and injected together with corticosteroid in the intervention group. DATA COLLECTION AND ANALYSIS Two authors independently performed the screening, data extraction, and 'Risk of bias' assessments. In case of insufficient information, we contacted the authors of the original studies or estimated the data. We grouped the outcome data into four time points of assessment: immediate (≤ 2 weeks), short term (> 2 weeks but ≤ 3 months), intermediate term (> 3 months but < 12 months), and long term (≥ 12 months). We assessed the overall quality of evidence for each outcome and time point using the GRADE approach. MAIN RESULTS We included 25 clinical trials (from 29 publications) investigating the effects of epidural corticosteroid injections compared to placebo in patients with lumbosacral radicular pain. The included studies provided data for a total of 2470 participants with a mean age ranging from 37.3 to 52.8 years. Seventeen studies included participants with lumbosacral radicular pain with a diagnosis based on clinical assessment and 15 studies included participants with mixed duration of symptoms. The included studies were conducted mainly in North America and Europe. Fifteen studies did not report funding sources, five studies reported not receiving funding, and five reported receiving funding from a non-profit or government source. Eight trials reported data on pain intensity, 12 reported data on disability, and eight studies reported data on adverse events. The duration of the follow-up assessments ranged from 12 hours to 1 year. We considered eight trials to be of high quality because we judged them as having low risk of bias in four out of the five bias domains. We identified one ongoing trial in a trial registry. Epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing leg pain at short-term follow-up (mean difference (MD) -4.93, 95% confidence interval (CI) -8.77 to -1.09 on a 0 to 100 scale; 8 trials, n = 949; moderate-quality evidence (downgraded for risk of bias)). For disability, epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing disability at short-term follow-up (MD -4.18, 95% CI -6.04 to -2.17, on a 0 to 100 scale; 12 trials, n = 1367; moderate-quality evidence (downgraded for risk of bias)). The treatment effects are small, however, and may not be considered clinically important by patients and clinicians (i.e. MD lower than 10%). Most trials provided insufficient information on how or when adverse events were assessed (immediate or short-term follow-up) and only reported adverse drug reactions - that is, adverse events that the trialists attributed to the study treatment. We are very uncertain that epidural corticosteroid injections make no difference compared to placebo injection in the frequency of minor adverse events (risk ratio (RR) 1.14, 95% CI 0.91 to 1.42; 8 trials, n = 877; very low quality evidence (downgraded for risk of bias, inconsistency and imprecision)). Minor adverse events included increased pain during or after the injection, non-specific headache, post-dural puncture headache, irregular periods, accidental dural puncture, thoracic pain, non-local rash, sinusitis, vasovagal response, hypotension, nausea, and tinnitus. One study reported a major drug reaction for one patient on anticoagulant therapy who had a retroperitoneal haematoma as a complication of the corticosteroid injection. AUTHORS' CONCLUSIONS This study found that epidural corticosteroid injections probably slightly reduced leg pain and disability at short-term follow-up in people with lumbosacral radicular pain. In addition, no minor or major adverse events were reported at short-term follow-up after epidural corticosteroid injections or placebo injection. Although the current review identified additional clinical trials, the available evidence still provides only limited support for the use of epidural corticosteroid injections in people with lumbosacral radicular pain as the treatment effects are small, mainly evident at short-term follow-up and may not be considered clinically important by patients and clinicians (i.e. mean difference lower than 10%). According to GRADE, the quality of the evidence ranged from very low to moderate, suggesting that further studies are likely to play an important role in clarifying the efficacy and tolerability of this treatment. We recommend that further trials should attend to methodological features such as appropriate allocation concealment and blinding of care providers to minimise the potential for biased estimates of treatment and harmful effects.
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Affiliation(s)
- Crystian B Oliveira
- São Paulo State UniversityDepartment of PhysiotherapyRua Roberto Simonsen, 305Presidente PrudenteSão PauloBrazilCEP 19060‐900
| | - Christopher G Maher
- University of SydneySydney School of Public HealthLevel 10 North, King George V Building, Missenden Road, CamperdownSydneyNSWAustralia2050
| | - Manuela L Ferreira
- Sydney Medical School, The University of SydneyInstitute of Bone and Joint Research, The Kolling InstituteSydneyNSWAustralia
| | - Mark J Hancock
- Macquarie UniversityDiscipline of Physiotherapy, Faculty of Medicine and Health SciencesSydneyAustralia
| | - Vinicius Cunha Oliveira
- Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM)Departamento de FisioterapiaCampus JK ‐ Rodovia MGT 367‐ Km 583, nº 5000 ‐ Alto da JacubaDiamantinaMinas GeraisBrazil39100‐000
| | - Andrew J McLachlan
- University of SydneyFaculty of PharmacyA15 ‐ PharmacyRoom N405SydneyNSWAustralia2006
| | - Bart W Koes
- University of Southern DenmarkCenter for Muscle and HealthOdenseDenmark
| | - Paulo H Ferreira
- The University of SydneyDiscipline of Physiotherapy, Faculty of Health Sciences75 East StreetSydneyLidcombe NSWAustralia1825
| | - Steven P Cohen
- Johns Hopkins University School of MedicineBlaustein Pain Treatment Center, Department of AnesthesiologyBaltimoreMarylandUSA
| | - Rafael Zambelli Pinto
- Universidade Federal de Minas Gerais (UFMG)Department of PhysiotherapyAv. Pres. Antônio Carlos, 6627Belo Horizonte ‐ MGBelo Horizonte, Minas GeraisMinas Gerais(MG)BrazilCEP 31270‐901
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13
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Abdel Shaheed C, Maher CG, Buchbinder R, Ng B, Enke O, Guzowski R, McLachlan AJ, Day RO, Richards B, Latimer J, Lin CWC. Efficacy and harms of orally, intramuscularly or intravenously administered glucocorticoids for sciatica: A systematic review and meta-analysis. Eur J Pain 2020; 24:518-535. [PMID: 31715647 DOI: 10.1002/ejp.1505] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 11/03/2019] [Accepted: 11/05/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Sciatica can be a debilitating condition and there is limited guidance on the use of glucocorticoids administered via the oral, intramuscular or intravenous route for this condition. These represent viable treatment options in the primary care setting. OBJECTIVE To evaluate the evidence on efficacy and harms of oral, IM and IV glucocorticoid administration for sciatica. DATABASES AND DATA TREATMENT MEDLINE, EMBASE, CENTRAL, CINAHL, PsycINFO (inception to October 2018) were searched for randomised placebo-controlled trials evaluating oral, IV or IM glucocorticoid administration for sciatica. Two authors extracted outcomes data. Continuous pain and disability outcomes were converted to a 0 (no pain/disability) to 100 (worst pain/disability) scale. Data were pooled using a random effects model. Overall quality of evidence was assessed using GRADE. Primary outcomes were leg pain and disability. Primary follow-up period was the immediate-term (<2 weeks from administration). We also considered adverse events. RESULTS Nine trials were eligible. One study [n = 27] provided low quality evidence of a small reduction in disability with early administration of oral prednisone (within 1 week); MD -13.4 [-23.3, -3.5] but not for pain MD -2.5 [-16.9, 11.9]. There was low quality evidence from one study [n = 78] of moderate reduction in disability and small reduction in pain with early (within 72 hr of symptom onset) single intramuscular administration of methylprednisolone acetate; MD -24.5 [-38.8, -10.2] and -14.0 [-27.4, -0.6], respectively. There were no immediate-term benefits with IV administration. CONCLUSION The effects of glucocorticoids on immediate-term leg pain or disability are uncertain. Future large high quality trials are needed to resolve this uncertainty.
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Affiliation(s)
| | - Chris G Maher
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Sydney Local Health District, Institute for Musculoskeletal Health, Sydney, NSW, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne Victoria, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Beverly Ng
- Department of Rheumatology, St George Hospital Kogarah, Sydney, NSW, Australia
| | - Oliver Enke
- Department of Orthopaedics, Nepean Hospital, Kingswood, NSW, Australia
| | - Robert Guzowski
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Andrew J McLachlan
- Faculty of Pharmacy, University of Sydney, Sydney, NSW, Australia.,Centre for Research Excellence in Medicines and Ageing, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Ric O Day
- St Vincent's Hospital Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia.,Department of Pharmacology, University of New South Wales, Sydney, NSW, Australia
| | - Bethan Richards
- Department of Rheumatology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Jane Latimer
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
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Ko S, Chae S, Choi W, Kwon J. Prolonged pain reducing effect of sodium hyaluronate-carboxymethyl cellulose solution in the selective nerve root block (SNRB) of lumbar radiculopathy: a prospective, double-blind, randomized controlled clinical trial. Spine J 2019; 19:578-586. [PMID: 30395961 DOI: 10.1016/j.spinee.2018.10.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 10/12/2018] [Accepted: 10/15/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND The pattern of linear graph schematized by visual analogue scale (VAS) score displaying pain worsening between 2 days and 2 weeks after selective nerve root block (SNRB) is called rebound pain. PURPOSE The purpose of this study was to determine if sodium hyaluronate and carboxymethyl cellulose solution (HA-CMC sol) injection could reduce the occurrence of rebound pain at 3 days to 2 weeks after SNRB in patients with radiculopathy compared with injection with corticosteroids and local anesthetics alone. STUDY DESIGN/SETTING Double blinded randomized controlled clinical trial. PATIENT SAMPLE A total of 44 patients (23 of 24 patients in the Guardix group and 21 of 24 patients in the control group) who finished the follow-up session were subjects of this study. OUTCOME MEASUREMENT Patients were asked to write down their average VAS pain scores daily for 12 weeks. Functional outcomes were assessed by Oswestry Disability Index, Roland Morris Disability Questionnaire , and Short Form-36. METHOD A cocktail of corticosteroids, 1% lidocaine, 0.5% Bupivacaine, and 1 mL of normal saline was used for the control group whereas a cocktail of corticosteroids, 1% lidocaine, 0.5% Bupivacaine, and 1 mL of HA-CMC solution was used for the G group. Study participants were randomized into one of two treatment regimens. They were followed up for 3 months. RESULTS VAS score at 2 weeks after the procedure was 4.19±1.32 in the control group, which was significantly (p<.05) higher than that (2.43±1.24) in the G group. VAS score at 6 weeks after the procedure was 4.00±1.23 in the control group and 3.22±1.45 in the G group, showing no significant (p=.077) difference between the two groups. There were no significant differences in functional outcomes at 6 or 12 weeks after the procedure. CONCLUSIONS Compared with conventional cocktail used for SNRB, addition of HA-CMC sol showed effective control of rebound pain at 3 days to 2 weeks after the procedure.
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Affiliation(s)
- Sangbong Ko
- Department of Orthopedic Surgery, College of Medicine, Daegu Catholic University, Daegu city, Korea
| | - Seungbum Chae
- Department of Orthopedic Surgery, College of Medicine, Daegu Catholic University, Daegu city, Korea
| | - Wonkee Choi
- Department of Orthopedic Surgery, College of Medicine, Daegu Catholic University, Daegu city, Korea
| | - Jaibum Kwon
- Department of Orthopedic Surgery, College of Medicine, Daegu Catholic University, Daegu city, Korea.
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Nonsurgical medical treatment in the management of pain due to lumbar disc prolapse: A network meta-analysis. Semin Arthritis Rheum 2019; 49:303-313. [PMID: 30940466 DOI: 10.1016/j.semarthrit.2019.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 02/20/2019] [Accepted: 02/22/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Evaluate the comparative effectiveness of treatment strategies for patients with pain due to lumbar disc prolapse (LDP). METHODS PubMed, EMBASE, and the Cochrane Database were searched through September 2017. Randomized controlled trials on LDP reporting on pain intensity and/or global pain effects which compared included treatments head-to-head, against placebo, and/or against conventional care were included. Study data were independently double-extracted and data on patient traits and outcomes were collected. Risk of bias was assessed using the Cochrane risk of bias tool. Separate Bayesian network meta-analyses were undertaken to synthesize direct and indirect, short-term and long-term outcomes, summarized as odds ratios (OR) or weighted mean differences (WMD) with 95% credible intervals (CI) as well as surface under the cumulative ranking curve (SUCRA) values. RESULTS 58 studies in global effects and 74 studies in pain intensity analysis were included. Thirty-eight (65.5%) of these studies reported a possible elevated risk of bias. Autonomic drugs and transforminal epidural steroid injections (TESIs) had the highest SUCRA scores at short-term follow up (86.7 and 83.5 respectively), while Cytokines/Immunomodulators and TESI had the highest SUCRA values at long-term-follow-up in the global effect's analysis (86.6 and 80.9 respectively). Caudal steroid injections and TESIs had the highest SUCRA scores at short-term follow up (79.4 and 75.9 respectively), while at long-term follow-up biological agents and manipulation had the highest SUCRA scores (86.4 and 68.5 respectively) for pain intensity. Some treatments had few studies and/or no associated placebo-controlled trials. Studies often did not report on co-interventions, systematically differed, and reported an overall elevated risk of bias. CONCLUSION No treatment stands out as superior when compared on multiple outcomes and time periods but TESIs show promise as an effective short-term treatment. High quality studies are needed to confirm many nodes of this network meta-analysis.
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Oliveira CB, Maher CG, Pinto RZ, Traeger AC, Lin CWC, Chenot JF, van Tulder M, Koes BW. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:2791-2803. [PMID: 29971708 DOI: 10.1007/s00586-018-5673-2] [Citation(s) in RCA: 697] [Impact Index Per Article: 116.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 06/17/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of this study was to provide an overview of the recommendations regarding the diagnosis and treatment contained in current clinical practice guidelines for patients with non-specific low back pain in primary care. We also aimed to examine how recommendations have changed since our last overview in 2010. METHOD The searches for clinical practice guidelines were performed for the period from 2008 to 2017 in electronic databases. Guidelines including information regarding either the diagnosis or treatment of non-specific low back pain, and targeted at a multidisciplinary audience in the primary care setting, were considered eligible. We extracted data regarding recommendations for diagnosis and treatment, and methods for development of guidelines. RESULTS We identified 15 clinical practice guidelines for the management of low back pain in primary care. For diagnosis of patients with non-specific low back pain, the clinical practice guidelines recommend history taking and physical examination to identify red flags, neurological testing to identify radicular syndrome, use of imaging if serious pathology is suspected (but discourage routine use), and assessment of psychosocial factors. For treatment of patients with acute low back pain, the guidelines recommend reassurance on the favourable prognosis and advice on returning to normal activities, avoiding bed rest, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and weak opioids for short periods. For treatment of patients with chronic low back pain, the guidelines recommend the use of NSAIDs and antidepressants, exercise therapy, and psychosocial interventions. In addition, referral to a specialist is recommended in case of suspicion of specific pathologies or radiculopathy or if there is no improvement after 4 weeks. While there were a few discrepancies across the current clinical practice guidelines, a substantial proportion of recommendations was consistently endorsed. In the current review, we identified some differences compared to the previous overview regarding the recommendations for assessment of psychosocial factors, the use of some medications (e.g., paracetamol) as well as an increasing amount of information regarding the types of exercise, mode of delivery, acupuncture, herbal medicines, and invasive treatments. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Crystian B Oliveira
- Departamento de Fisioterapia, Faculdade de Ciências e Tecnologia, Universidade Estadual Paulista (UNESP), Presidente Prudente, SP, Brazil
| | - Chris G Maher
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | - Rafael Z Pinto
- Department of Physical Therapy, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Adrian C Traeger
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | - Chung-Wei Christine Lin
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | - Jean-François Chenot
- Department of General Practice, Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Maurits van Tulder
- Department of Health Sciences, Faculty of Sciences and Amsterdam Movement Sciences Institute, Vrije Universiteit, Amsterdam, The Netherlands
| | - Bart W Koes
- Department of General Practice, Erasmus Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
- Center for Muscle and Health, University of Southern Denmark, Odense, Denmark.
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Guo JR, Jin XJ, Shen HC, Wang H, Zhou X, Liu XQ, Zhu NN. A Comparison of the Efficacy and Tolerability of the Treatments for Sciatica: A Network Meta-Analysis. Ann Pharmacother 2017; 51:1041-1052. [PMID: 28745066 DOI: 10.1177/1060028017722008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background: There remains a lack of a systematic summary of the efficacy and safety of various medicines for sciatica, and discrepancies among these exist. Objective: The aim of this study is to comprehensively assess the efficacy of and tolerance to several medical options for the treatment of sciatica. Methods: We performed a network meta-analysis and illustrated the results by the mean difference or odds ratio. The surface under the cumulative ranking curve (SUCRA) was used for indicating the preferable treatments. All data analyses and graphs were achieved via R 3.3.2 and Stata 13.0. Results: The subcutaneous anti–tumor necrosis factor–α (anti-TNF-α) was superior to the epidural steroid + anesthetic in reducing lumbar pain in both acute + chronic sciatica patients and acute sciatica patients. The epidural steroid demonstrated a better ability regarding the Oswestry disability score (ODI) compared to the subcutaneous anti-TNF-α. In addition, for total pain relief, the use of nonsteroidal antiinflammatory drugs was inferior to the epidural steroid + anesthetic. The epidural anesthetic and epidural steroid + anesthetic both demonstrated superiority over the epidural steroid and intramuscular steroid. The intravenous anti-TNF-α ranked first in leg pain relief, while the subcutaneous anti-TNF-α ranked first in lumbar pain relief, and the epidural steroid ranked first in the ODI on the basis of SUCRA. In addition, their safety outcome (withdrawal) rankings were all medium to high. Conclusions: Intravenous and subcutaneous anti-TNF-α were identified as the optimal treatments for both acute + chronic sciatica patients and acute sciatica patients. In addition, the epidural steroid was also recommended as a good intervention due to its superiority in reducing ODI.
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Affiliation(s)
- Jian-Rong Guo
- Gongli Hospital, the Second Military Medical University, Shanghai, People’s Republic of China
| | - Xiao-Ju Jin
- Yijishan Hospital, Wannan Medical College, Wuhu, People’s Republic of China
| | - Hua-Chun Shen
- Ningbo No. 2 Hospital, Ningbo, People’s Republic of China
| | - Huan Wang
- Gongli Hospital, the Second Military Medical University, Shanghai, People’s Republic of China
| | - Xun Zhou
- Gongli Hospital, the Second Military Medical University, Shanghai, People’s Republic of China
| | - Xiao-Qian Liu
- Gongli Hospital, the Second Military Medical University, Shanghai, People’s Republic of China
| | - Na-Na Zhu
- Gongli Hospital, the Second Military Medical University, Shanghai, People’s Republic of China
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Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M, Andersen MØ, Fournier G, Højgaard B, Jensen MB, Jensen LD, Karbo T, Kirkeskov L, Melbye M, Morsel-Carlsen L, Nordsteen J, Palsson TS, Rasti Z, Silbye PF, Steiness MZ, Tarp S, Vaagholt M. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:60-75. [DOI: 10.1007/s00586-017-5099-2] [Citation(s) in RCA: 294] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/19/2017] [Accepted: 04/10/2017] [Indexed: 01/08/2023]
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Ko S, Kim S, Kim J, Oh T. The Effectiveness of Oral Corticosteroids for Management of Lumbar Radiating Pain: Randomized, Controlled Trial Study. Clin Orthop Surg 2016; 8:262-7. [PMID: 27583108 PMCID: PMC4987309 DOI: 10.4055/cios.2016.8.3.262] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 04/19/2016] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Although both pregabalin and gabapentin are known to be useful for treating lumbar radiating pain and reducing the incidence of surgery, the oral corticosteroids sometimes offer a dramatic effect on severe radiating pain despite the lack of scientific evidence. METHODS A total of 54 patients were enrolled among 703 patients who complained of lumbar radiating pain. Twenty patients who received an oral corticosteroid was classified as group A and 20 patients who received the control drugs (pregabalin or gabapentin) as group B. Oswestry Disability Index (ODI), Revised Roland Morris disability questionnaire (RMDQ), Short Form 36 (SF-36) questionnaire, lumbar radiating pain, objective patient satisfaction, and objective improvement of patients or physicians were assessed at 2, 6, and 12 weeks after medication. RESULTS No difference in the sex ratio and age was observed between the groups (p = 0.70 and p = 0.13, respectively). Group A showed greater improvement in radiating pain after 2, 6, and 12 weeks than group B (p < 0.001, p = 0.001, and p < 0.001, respectively). No differences were observed between the groups in satisfaction at the beginning and 12 weeks after taking the medication (p = 0.062 and p = 0.061, respectively) and in objective improvement of patients and physicians (p = 0.657 and p = 0.748, respectively). Group A was less disabled and had greater physical health scores than group B (p = 0.014 and p = 0.017, respectively). CONCLUSIONS Oral corticosteroids for the treatment of lumbar radiating pain can be more effective in pain relief than gabapentin or pregabalin. The satisfaction of patients and physicians with the drug and objective improvement status were not inferior to that with gabapentin or pregabalin.
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Affiliation(s)
- Sangbong Ko
- Department of Orthopaedic Surgery, Daegu Catholic University Medical Center, Daegu, Korea
| | - Sungguk Kim
- Department of Orthopaedic Surgery, Daegu Catholic University Medical Center, Daegu, Korea
| | - Jaejung Kim
- Department of Orthopaedic Surgery, Daegu Catholic University Medical Center, Daegu, Korea
| | - Taebum Oh
- Department of Orthopaedic Surgery, Daegu Catholic University Medical Center, Daegu, Korea
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Vorobeychik Y, Sharma A, Smith CC, Miller DC, Stojanovic MP, Lobel SM, Valley MA, Duszynski B, Kennedy DJ. The Effectiveness and Risks of Non-Image-Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data. PAIN MEDICINE 2016; 17:2185-2202. [PMID: 28025354 DOI: 10.1093/pm/pnw091] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the effectiveness and risks of non-image-guided lumbar interlaminar epidural steroid injections. DESIGN Systematic review. INTERVENTIONS Three reviewers with formal training and certification in evidence-based medicine searched the literature on non-image-guided lumbar interlaminar epidural steroid injections. A larger team of seven reviewers independently assessed the methodology of studies found and appraised the quality of the evidence presented. OUTCOME MEASURES The primary outcome assessed was pain relief. Other outcomes such as functional improvement, reduction in surgery rate, decreased use of opioids, and complications were noted, if reported. The evidence was appraised in accordance with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system of evaluating evidence. RESULTS The searches yielded 92 primary publications addressing non-image-guided lumbar interlaminar epidural steroid injections. The evidence supporting the effectiveness of these injections for pain relief and functional improvement in patients with lumbar radicular pain due to disc herniation or neurogenic claudication secondary to lumbar spinal stenosis is limited. This procedure may provide short-term benefit in the first 3-6 weeks. The small number of case reports on significant risks suggests these injections are relatively safe. In accordance with GRADE, the quality of evidence is very low. CONCLUSIONS In patients with lumbar radicular pain secondary to disc herniation or neurogenic claudication due to spinal stenosis, non-image-guided lumbar interlaminar epidural steroid injections appear to have clinical effectiveness limited to short-term pain relief. Therefore, in a contemporary medical practice, these procedures should be restricted to the rare settings where fluoroscopy is not available.
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Affiliation(s)
- Yakov Vorobeychik
- *Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania
| | - Anil Sharma
- Spine and Pain Centers, New Jersey and New York
| | - Clark C Smith
- Columbia University College of Physicians and Surgeons, New York, New York
| | | | - Milan P Stojanovic
- Anesthesiology, Critical Care and Pain Medicine Service, VA Boston Healthcare System, Boston, Massachusetts
| | - Steve M Lobel
- Medical Associates of North Georgia, Canton, Georgia
| | | | | | - David J Kennedy
- Department of Orthopedics, Stanford University, Redwood City, California, USA
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Lee JH, Lee SH. Comparison of Clinical Efficacy Between Interlaminar and Transforaminal Epidural Injection in Patients With Axial Pain due to Cervical Disc Herniation. Medicine (Baltimore) 2016; 95:e2568. [PMID: 26825899 PMCID: PMC5291569 DOI: 10.1097/md.0000000000002568] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Transforaminal (TF) approach is preferred by physician to interlaminar (IL) approach because it can deliver injectates directly around nerve root and dorsal root ganglion, which is regarded as main pain sources. Axial neck pain is originated from sinuvertebral nerve located in ventral epidural spaces, which has been described to be related to central or paramedian disc herniation. It is very questionable that TF injection is also more effective than IL injection in the patients with axial neck or interscapular pain. This study was to evaluate clinical efficacy of cervical epidural injection in patients with axial pain due to cervical disc herniation and to compare the clinical outcomes between TF and IL approaches. Fifty-six and 52 patients who underwent IL and TF epidural injections, respectively, for axial neck/interscapular pain due to central or paramedian cervical disc herniation were included. Numeric Rating Scale (NRS) and Neck Disability Index (NDI) were compared between both groups at 2 and 8 weeks after treatment. Successful pain relief was defined if a 50% or more reduction of NRS score was achieved in comparison with pretreatment one. Successful functional improvement was defined if at least a 40% reduction of NDI was obtained. Overall, 79 (73.1%) and 57 (52.8%) among 108 patients showed successful pain relief at 2 and 8 weeks, respectively. Seventy-six (70.4%) and 52 (48.1%) had successful functional improvement at 2 and 8 weeks, respectively. The IL and TF groups showed no significant difference in proportion of successful results of NRS 2 weeks (73.2% vs 67.3%) and 8 weeks (48.2% vs 48.1%). Also, no significant difference was obtained in proportion of successful NDI between 2 groups at 2 weeks (75.0% vs 71.2%) and 8 weeks (53.6% vs 51.9%). Cervical epidural injection showed favorable results in 2 weeks and moderate results in 8 weeks in patients with axial pain due to cervical disc herniation. IL and TF showed no significant difference in clinical efficacy. Considering TF was relevant to more serious side effects, IL was more recommendable in these patients.
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Affiliation(s)
- Jung Hwan Lee
- From the Departments of Physical Medicine and Rehabilitation (JHL) and Neurosurgery (S-HL), Wooridul Spine Hospital, Seoul, Korea
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Chou R, Hashimoto R, Friedly J, Fu R, Bougatsos C, Dana T, Sullivan SD, Jarvik J. Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med 2015; 163:373-81. [PMID: 26302454 DOI: 10.7326/m15-0934] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Use of epidural corticosteroid injections is increasing. PURPOSE To review evidence on the benefits and harms of epidural corticosteroid injections in adults with radicular low back pain or spinal stenosis of any duration. DATA SOURCES Ovid MEDLINE (through May 2015), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, prior systematic reviews, and reference lists. STUDY SELECTION Randomized trials of epidural corticosteroid injections versus placebo interventions, or that compared epidural injection techniques, corticosteroids, or doses. DATA EXTRACTION Dual extraction and quality assessment of individual studies, which were used to determine the overall strength of evidence (SOE). DATA SYNTHESIS 30 placebo-controlled trials evaluated epidural corticosteroid injections for radiculopathy, and 8 trials were done for spinal stenosis. For radiculopathy, epidural corticosteroids were associated with greater immediate-term reduction in pain (weighted mean difference on a scale of 0 to 100, -7.55 [95% CI, -11.4 to -3.74]; SOE, moderate), function (standardized mean difference after exclusion of an outlier trial, -0.33 [CI, -0.56 to -0.09]; SOE, low), and short-term surgery risk (relative risk, 0.62 [CI, 0.41 to 0.92]; SOE, low). Effects were below predefined minimum clinically important difference thresholds, and there were no longer-term benefits. Limited evidence showed no clear effects of technical factors, patient characteristics, or comparator interventions on estimates. There were no clear effects of epidural corticosteroid injections for spinal stenosis (SOE, low to moderate). Serious harms were rare, but harms reporting was suboptimal (SOE, low). LIMITATIONS The review was restricted to English-language studies. Some meta-analyses were based on small numbers of trials (particularly for spinal stenosis), and most trials had methodological shortcomings. CONCLUSION Epidural corticosteroid injections for radiculopathy were associated with immediate reductions in pain and function. However, benefits were small and not sustained, and there was no effect on long-term surgery risk. Limited evidence suggested no effectiveness for spinal stenosis.
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Affiliation(s)
- Roger Chou
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Robin Hashimoto
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Janna Friedly
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Rongwei Fu
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Christina Bougatsos
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Tracy Dana
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Sean D. Sullivan
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Jeffrey Jarvik
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
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Murphy K, Muto M, Steppan J, Meaders T, Boxley C. Treatment of Contained Herniated Lumbar Discs With Ozone and Corticosteroid: A Pilot Clinical Study. Can Assoc Radiol J 2015; 66:377-84. [PMID: 26092159 DOI: 10.1016/j.carj.2015.01.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 12/31/2014] [Accepted: 01/28/2015] [Indexed: 11/30/2022] Open
Abstract
PURPOSE The primary objective of this pilot study was to compare pain and function scores from patients before and after an ozone injection in combination with steroids and bupivacaine to treat herniated discs. A secondary objective was to correct some of the methodological weaknesses of some previously published ozone studies. METHODS Fifty patients were enrolled; 1-3 mL of 2 wt% ozone in 98 wt% oxygen was delivered into the nucleus pulposus, and 7-9 mL into the adjacent paravertebral tissues. The oxygen/ozone treatment was followed by a periganglionic injection of corticosteroid and bupivacaine. All patients were evaluated 1 month after the treatment to quantify improvement in pain and function, and to monitor for potential adverse events. RESULTS Forty-four patients had intradiscal injections and were included in the analysis. After 1 treatment, 75.0% showed significant improvement in pain based on the visual analog scale (improvement >1.8), 72.7% showed significant improvement in function based on the Oswestry disability index (improvement >15%), and 79.5% showed improvement based on the modified MacNab criteria. There were no adverse events associated with the treatment. CONCLUSIONS Patients showed significant improvement in pain and function after receiving ozone injections in combination with steroids and bupivacaine for the treatment of herniated discs. Because of the lack of a control group and short follow-up times, conclusions about the safety and efficacy of ozone injections for the treatment of herniated discs are not warranted. However, the results provide sufficient evidence that the risk and expense of an additional randomized controlled study is merited.
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Affiliation(s)
- Kieran Murphy
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
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Lewis RA, Williams NH, Sutton AJ, Burton K, Din NU, Matar HE, Hendry M, Phillips CJ, Nafees S, Fitzsimmons D, Rickard I, Wilkinson C. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. Spine J 2015; 15:1461-77. [PMID: 24412033 DOI: 10.1016/j.spinee.2013.08.049] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 07/09/2013] [Accepted: 08/23/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND There are numerous treatment approaches for sciatica. Previous systematic reviews have not compared all these strategies together. PURPOSE To compare the clinical effectiveness of different treatment strategies for sciatica simultaneously. STUDY DESIGN Systematic review and network meta-analysis. METHODS We searched 28 electronic databases and online trial registries, along with bibliographies of previous reviews for comparative studies evaluating any intervention to treat sciatica in adults, with outcome data on global effect or pain intensity. Network meta-analysis methods were used to simultaneously compare all treatment strategies and allow indirect comparisons of treatments between studies. The study was funded by the UK National Institute for Health Research Health Technology Assessment program; there are no potential conflict of interests. RESULTS We identified 122 relevant studies; 90 were randomized controlled trials (RCTs) or quasi-RCTs. Interventions were grouped into 21 treatment strategies. Internal and external validity of included studies was very low. For overall recovery as the outcome, compared with inactive control or conventional care, there was a statistically significant improvement following disc surgery, epidural injections, nonopioid analgesia, manipulation, and acupuncture. Traction, percutaneous discectomy, and exercise therapy were significantly inferior to epidural injections or surgery. For pain as the outcome, epidural injections and biological agents were significantly better than inactive control, but similar findings for disc surgery were not statistically significant. Biological agents were significantly better for pain reduction than bed rest, nonopioids, and opioids. Opioids, education/advice alone, bed rest, and percutaneous discectomy were inferior to most other treatment strategies; although these findings represented large effects, they were statistically equivocal. CONCLUSIONS For the first time, many different treatment strategies for sciatica have been compared in the same systematic review and meta-analysis. This approach has provided new data to assist shared decision-making. The findings support the effectiveness of nonopioid medication, epidural injections, and disc surgery. They also suggest that spinal manipulation, acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be considered. The findings do not provide support for the effectiveness of opioid analgesia, bed rest, exercise therapy, education/advice (when used alone), percutaneous discectomy, or traction. The issue of how best to estimate the effectiveness of treatment approaches according to their order within a sequential treatment pathway remains an important challenge.
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Affiliation(s)
- Ruth A Lewis
- North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP.
| | - Nefyn H Williams
- North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP; North Wales Organisation for Randomised Trials in Health (NWORTH), Bangor University, The Normal Site, Holyhead Road, Gwynedd, UK LL57 2PZ
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, 22-28 Princess Road West, Leicester, UK LE1 6TP
| | - Kim Burton
- Spinal Research Institute, University of Huddersfield, Queensgate, Huddersfield, UK HD1 3DH
| | - Nafees Ud Din
- North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP
| | - Hosam E Matar
- Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield, UK S5 7AU
| | - Maggie Hendry
- North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP
| | - Ceri J Phillips
- School of Human and Health Sciences, Swansea University, Singleton Park, Swansea, UK SA2 8PP
| | - Sadia Nafees
- North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP
| | - Deborah Fitzsimmons
- Spinal Research Institute, University of Huddersfield, Queensgate, Huddersfield, UK HD1 3DH
| | - Ian Rickard
- Green Oak, Dolydd Terrace, Betws-Y-Coed, UK LL24 0BU
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP
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Manchikanti L, Benyamin RM, Falco FJE, Kaye AD, Hirsch JA. Do Epidural Injections Provide Short- and Long-term Relief for Lumbar Disc Herniation? A Systematic Review. Clin Orthop Relat Res 2015; 473:1940-56. [PMID: 24515404 PMCID: PMC4419020 DOI: 10.1007/s11999-014-3490-4] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND As part of a comprehensive nonsurgical approach, epidural injections often are used in the management of lumbar disc herniation. Recent guidelines and systematic reviews have reached different conclusions about the efficacy of epidural injections in managing lumbar disc herniation. QUESTIONS/PURPOSES In this systematic review, we determined the efficacy (pain relief and functional improvement) of the three anatomic approaches (caudal, lumbar interlaminar, and transforaminal) for epidural injections in the treatment of disc herniation. METHODS We performed a literature search from 1966 to June 2013 in PubMed, Cochrane library, US National Guideline Clearinghouse, previous systematic reviews, and cross-references for trials studying all types of epidural injections in managing chronic or chronic and subacute lumbar disc herniation. We wanted only randomized controlled trials (RCTs) (either placebo or active controlled) to be included in our analysis, and 66 studies found in our search fulfilled these criteria. We then assessed the methodologic quality of these 66 studies using the Cochrane review criteria for RCTs. Thirty-nine studies were excluded, leaving 23 RCTs of high and moderate methodologic quality for analysis. Evidence for the efficacy of all three approaches for epidural injection under fluoroscopy was strong for short-term (< 6 months) and moderate for long-term (≥ 6 months) based on the Cochrane rating system with five levels of evidence (best evidence synthesis), with strong evidence denoting consistent findings among multiple high-quality RCTs and moderate evidence denoting consistent findings among multiple low-quality RCTs or one high-quality RCT. The primary outcome measure was pain relief, defined as at least 50% improvement in pain or 3-point improvement in pain scores in at least 50% of the patients. The secondary outcome measure was functional improvement, defined as 50% reduction in disability or 30% reduction in the disability scores. RESULTS Based on strong evidence for short-term efficacy from multiple high-quality trials and moderate evidence for long-term efficacy from at least one high quality trial, we found that fluoroscopic caudal, lumbar interlaminar, and transforaminal epidural injections were efficacious at managing lumbar disc herniation in terms of pain relief and functional improvement. CONCLUSIONS The available evidence suggests that epidural injections performed under fluoroscopy by trained physicians offer improvement in pain and function in well-selected patients with lumbar disc herniation.
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Affiliation(s)
- Laxmaiah Manchikanti
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA,
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Spijker-Huiges A, Vermeulen K, Winters JC, van Wijhe M, van der Meer K. Epidural Steroids for Lumbosacral Radicular Syndrome Compared to Usual Care: Quality of Life and Cost Utility in General Practice. Arch Phys Med Rehabil 2015; 96:381-7. [DOI: 10.1016/j.apmr.2014.10.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 10/13/2014] [Accepted: 10/15/2014] [Indexed: 12/27/2022]
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Epidural steroid injections for radicular lumbosacral pain: a systematic review. Phys Med Rehabil Clin N Am 2014; 25:471-89.e1-50. [PMID: 24787344 DOI: 10.1016/j.pmr.2014.02.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Most clinical guidelines do not recommend routine use of epidural steroid injections for the management of chronic low back pain. However, many clinicians do not adhere to these guidelines. This comprehensive evidence overview concluded that off-label epidural steroid injections provide small short-term but not long- term leg-pain relief and improvement in function; injection of steroids is no more effective than injection of local anesthetics alone; post-procedural complications are uncommon, but the risk of contamination and serious infections is very high. The evidence does not support routine use of off-label epidural steroid injections in adults with benign radicular lumbosacral pain.
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Spijker-Huiges A, Winters JC, van Wijhe M, Groenier K. Steroid injections added to the usual treatment of lumbar radicular syndrome: a pragmatic randomized controlled trial in general practice. BMC Musculoskelet Disord 2014; 15:341. [PMID: 25304934 PMCID: PMC4200234 DOI: 10.1186/1471-2474-15-341] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 08/13/2014] [Indexed: 11/30/2022] Open
Abstract
Background Lumbosacral radicular syndrome (LRS) is a self-limiting, benign, painful and impairing condition caused by lumbar disc herniation and inflammatory processes around the nerve root. Segmental epidural steroid injections (SESIs) are helpful to reduce radicular pain on a short-term basis. It is unknown whether SESIs are an effective addition to usual pain treatment of LRS in general practice. In our study, we assessed the effectiveness of SESIs on pain and disability as an addition to usual care for acute LRS in general practice. Methods A pragmatic, single-blinded, randomized controlled trial in Dutch general practice was conducted. Circumstances of daily practice were closely followed. Care as usual (CAU) was compared to care as usual combined with an additional SESI in 63 patients in the acute phase of LRS. To detect a minimal clinically important difference of 1.2 points on a numerical rating scale for back pain and a common within-group standard deviation of 1.7 with a two-tailed alpha of 0.05 and a power of 0.80, we needed 33 subjects in each group. Statistical analysis was carried out using mixed models. Results A small significant effect in favour of the intervention, corrected for age, sex and baseline values, was found for back pain, impairment and Roland-Morris disability score. The differences, though statistically significant, were too small to be considered clinically relevant. Patients from the intervention group were significantly more satisfied with the received treatment than patients from the control group. Conclusion We found a small, statistically significant, but not clinically relevant positive effect of SESIs on back pain, impairment and disability in acute LRS. We do not recommend implementing SESIs as an additional regular treatment option in general practice. Electronic supplementary material The online version of this article (doi:10.1186/1471-2474-15-341) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Antje Spijker-Huiges
- Department of General Practice, University Medical Centre Groningen, Postbus 196, FA20, 9700 AD Groningen, The Netherlands.
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Affiliation(s)
- Sung Kyu Kim
- Department of Orthopedic Surgery, Chonnam National University school of medicine, Gwangju, Korea
| | - Jae Yoon Chung
- Department of Orthopedic Surgery, Chonnam National University school of medicine, Gwangju, Korea
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Access routes and reported decision criteria for lumbar epidural drug injections: a systematic literature review. Skeletal Radiol 2013; 42:1683-92. [PMID: 23995263 DOI: 10.1007/s00256-013-1713-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 08/07/2013] [Accepted: 08/08/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To review lumbar epidural drug injection routes in relation to current practice and the reported criteria used for selecting a given approach. MATERIAL AND METHODS This was a HIPPA-compliant study. Employing a systematic search strategy, the MEDLINE and EMBASE databank as well as the Cochrane Library were searched for studies on epidural drug injections. The following data were noted: access route, level of injection, use of image guidance, and types and doses of injected drugs. Justifications for the use of a particular route were also noted. Data were presented using descriptive statistics. RESULTS A total of 1,211 scientific studies were identified, of which 91 were finally included (7.5%). The interlaminar access route was used in 44 of 91 studies (48.4%), the transforaminal in 37 of 91 studies (40.7%), and the caudal pathway in 26 of 91 studies (28.6%). The caudal pathway was favored in the older studies whereas the transforaminal route was favored in recent studies. Decision criteria related to correct needle placement, concentration of injected drug at lesion site, technical complexity, costs, and potential complications. Injection was usually performed on the level of the lesion using local anesthetics (71 of 91 studies, 78.0%), steroids (all studies) and image guidance (71 of 91 studies, 78%). CONCLUSIONS The most commonly used access routes for epidural drug injection are the interlaminar and transforaminal pathways at the level of the pathology. Transforaminal routes are being performed with increasing frequency in recent years.
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Epidural steroid injection therapy for low back pain: a meta-analysis. Int J Technol Assess Health Care 2013; 29:244-53. [PMID: 23769210 DOI: 10.1017/s0266462313000342] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES The aim of this study was to systematically assess the long-term (≥ 6 months) benefits of epidural steroid injection therapies for patients with low back pain. METHODS We identified randomized controlled trials by database searches up to October 2011 and by additional hand searches without language restrictions. Randomized controlled trials on the effects of epidurals for low back pain with follow-up for at least 6 months were included. Outcomes considered were pain relief, functional improvement in 6 to 12 months after epidural steroid injection treatment and the number of patients who underwent subsequent surgery. Meta-analysis was performed using a random-effects model. RESULTS Twenty-nine articles were selected. The meta-analysis suggested that a significant treatment effect on pain was noted at 6 months of follow-up (weighted mean difference [WMD], -0.41; 95 percent confidence interval [CI], -0.66 to -0.16), but was no longer statistically significant after adjusting for the baseline pain score (WMD, -0.19; 95 percent CI, -0.61 to 0.24). Epidural steroid injection did not improve back-specific disability more than a placebo or other procedure. Epidural steroid injection did not significantly decrease the number of patients who underwent subsequent surgery compared with a placebo or other treatments (relative risk, 1.02; 95 percent CI, 0.83 to 1.24). CONCLUSIONS A long-term benefit of epidural steroid injections for low back pain was not suggested at 6 months or longer. Introduction of selection bias in the majority of injection studies seems apparent. Baseline adjustment is essential when we evaluate pain as a main outcome of injection therapy.
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Radcliff K, Hilibrand A, Lurie JD, Tosteson TD, Delasotta L, Rihn J, Zhao W, Vaccaro A, Albert TJ, Weinstein JN. The impact of epidural steroid injections on the outcomes of patients treated for lumbar disc herniation: a subgroup analysis of the SPORT trial. J Bone Joint Surg Am 2012; 94:1353-8. [PMID: 22739998 PMCID: PMC3401142 DOI: 10.2106/jbjs.k.00341] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The Spine Patient Outcomes Research Trial (SPORT) is a prospective, multicenter study of operative versus nonoperative treatment of lumbar intervertebral disc herniation. It has been suggested that epidural steroid injections may help improve patient outcomes and lower the rate of crossover to surgical treatment. METHODS One hundred and fifty-four patients included in the intervertebral disc herniation arm of the SPORT who had received an epidural steroid injection during the first three months of the study and no injection prior to the study (the ESI group) were compared with 453 patients who had not received an injection during the first three months of the study or prior to the study (the No-ESI group). RESULTS There was a significant difference in the preference for surgery between groups (19% in the ESI group compared with 56% in the No-ESI group, p < 0.001). There was no difference in primary or secondary outcome measures at four years between the groups. A higher percentage of patients changed from surgical to nonsurgical treatment in the ESI group (41% versus 12% in the No-ESI, p < 0.001). CONCLUSIONS Patients with lumbar disc herniation treated with epidural steroid injection had no improvement in short or long-term outcomes compared with patients who were not treated with epidural steroid injection. There was a higher prevalence of crossover to nonsurgical treatment among surgically assigned ESI-group patients, although this was confounded by the increased baseline desire to avoid surgery among patients in the ESI group. Given these data, we concluded that more studies are necessary to establish the value of epidural steroid injection for symptomatic lumbar intervertebral disc herniation.
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Affiliation(s)
- Kristen Radcliff
- Department of Orthopedic Surgery, Thomas Jefferson University, Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107. E-mail address for K. Radcliff:
| | - Alan Hilibrand
- Department of Orthopedic Surgery, Thomas Jefferson University, Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107. E-mail address for K. Radcliff:
| | - Jon D. Lurie
- Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756
| | - Tor D. Tosteson
- Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756
| | - Lawrence Delasotta
- Department of Orthopedic Surgery, Thomas Jefferson University, Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107. E-mail address for K. Radcliff:
| | - Jeffrey Rihn
- Department of Orthopedic Surgery, Thomas Jefferson University, Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107. E-mail address for K. Radcliff:
| | - Wenyan Zhao
- Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756
| | - Alexander Vaccaro
- Department of Orthopedic Surgery, Thomas Jefferson University, Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107. E-mail address for K. Radcliff:
| | - Todd J. Albert
- Department of Orthopedic Surgery, Thomas Jefferson University, Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107. E-mail address for K. Radcliff:
| | - James N. Weinstein
- Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756
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KRYCH AARONJ, RICHMAN DANIEL, DRAKOS MARK, WEISS LEIGH, BARNES RONNIE, CAMMISA FRANK, WARREN RUSSELLF. Epidural Steroid Injection for Lumbar Disc Herniation in NFL Athletes. Med Sci Sports Exerc 2012; 44:193-8. [DOI: 10.1249/mss.0b013e31822d7599] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Rathmell JP. The argument for use of epidural steroid injections in management of acute radicular pain. Perm J 2011; 11:54-6. [PMID: 21412483 DOI: 10.7812/tpp/07-074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kim SB, Lee KW, Lee JH, Kim MA, Kim BH. The additional effect of hyaluronidase in lumbar interlaminar epidural injection. Ann Rehabil Med 2011; 35:405-11. [PMID: 22506151 PMCID: PMC3309212 DOI: 10.5535/arm.2011.35.3.405] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Accepted: 11/10/2010] [Indexed: 11/12/2022] Open
Abstract
Objective To evaluate the effect of hyaluronidase in lumbar interlaminar epidural injection (LIEI) for low back pain and sciatica. Method Sixty-one patients suffering from severe low back pain and sciatica were randomly allocated into three groups. Group T (n=18, mean duration of illness: 2.12±1.16 months) received lumbar interlaminar epidural injection (LIEI) with 2 ml triamcinolone (40 mg/ml) and 5 ml bupivacaine (0.25%). Group H (n=16, mean duration of illness: 2.05±1.12 months) received LIEI with 1,500 IU hyaluronidase and 5 ml bupivacaine (0.25%). Group TH (n=27, mean duration of illness: 2.16±1.65 months) received LIEI with 1,500 IU hyaluronidase, 2 ml triamcinolone (40 mg/ml), and 5 ml bupivacaine (0.25%). The effects were evaluated using the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) at preinjection and 2 weeks, 4 weeks, and 8 weeks after LIEI. Results Pain improved in all groups after 2 weeks (p<0.05). After 8 weeks, there was no significant difference in VAS improvement among the 3 groups. However, pain improved in 70.4% of Group TH compared with preinjection, in contrast to 44.4% of Group T and 31.3% of Group H. The ODI improved significantly only in Group TH after 8 weeks (p<0.05). Conclusion LIEI with triamcinolone and hyaluronidase is more effective for reducing pain after 8 weeks than injection with triamcinolone or hyaluronidase alone.
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Affiliation(s)
- Sang Beom Kim
- Department of Physical Medicine and Rehabilitation, Dong-A University College of Medicine, Busan 602-715, Korea
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Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review. Spine (Phila Pa 1976) 2010; 35:E488-504. [PMID: 20421859 DOI: 10.1097/brs.0b013e3181cc3f56] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A systematic review of randomized controlled trials. OBJECTIVE To determine the efficacy and adverse effects of conservative treatments for people who have lumbar disc herniation with associated radiculopathy (LDHR). SUMMARY OF BACKGROUND DATA Although conservative management is commonly used for people who have LDHR, the efficacy and adverse effects of conservative treatments for this condition are unclear. METHODS We searched 10 computer databases for trials published in English between 1971 and 2008. Trials focusing on people with referred leg symptoms and radiologic confirmation of a lumbar disc herniation were included if at least 1 group received a conservative and noninjection treatment. RESULTS Eighteen trials involving 1671 participants were included. Seven (39%) trials were considered of high quality. Meta-analysis on 2 high-quality trials revealed that advice is less effective than microdiscectomy surgery at short-term follow-up, but equally effective at long-term follow-up. Individual high-quality trials provided moderate evidence that stabilization exercises are more effective than no treatment, that manipulation is more effective than sham manipulation for people with acute symptoms and an intact anulus, and that no difference exists among traction, laser, and ultrasound. One trial showed some additional benefit from adding mechanical traction to medication and electrotherapy methods. Adverse events were associated with traction (pain, anxiety, lower limb weakness, and fainting) and ibuprofen (gastrointestinal events). CONCLUSION Advice is less effective than microdiscectomy in the short term but equally effective in the long term for people who have LDHR. Moderate evidence favors stabilization exercises over no treatment, manipulation over sham manipulation, and the addition of mechanical traction to medication and electrotherapy. There was no difference among traction, laser, and ultrasound. Adverse events were associated with traction and ibuprofen. Additional high-quality trials would allow firmer conclusions regarding adverse effects and efficacy.
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Epidural steroid injections are useful for the treatment of low back pain and radicular symptoms: pro. Curr Pain Headache Rep 2009; 13:31-4. [PMID: 19126368 DOI: 10.1007/s11916-009-0007-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Epidural steroid injection has been used to treat low back pain for many decades. Numerous randomized trials have examined the efficacy of this approach. This review details the findings of older systematic reviews, newer randomized controlled trials, and two recent systematic reviews that examine the effectiveness of this treatment. Collectively, studies in acute radicular pain due to herniated nucleus pulposus have failed to show that epidural steroid injection reduces long-term pain or obviates the need for surgery. Similarly, there is scant evidence that epidural steroids have any beneficial effect in those with acute low back pain without leg pain or in those with chronic low back or leg pain. However, most studies have demonstrated more rapid resolution of leg pain in those who received epidural steroid injections versus those who did not. The role of epidural steroid injections in the management of acute radicular pain due to herniated nucleus pulposus is simply to provide earlier pain relief.
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Datta S, Benyamin RM, Manchikanti L. Evidence-based practice of lumbar epidural injections. ACTA ACUST UNITED AC 2009. [DOI: 10.1053/j.trap.2009.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Roberts ST, Willick SE, Rho ME, Rittenberg JD. Efficacy of lumbosacral transforaminal epidural steroid injections: a systematic review. PM R 2009; 1:657-68. [PMID: 19627959 DOI: 10.1016/j.pmrj.2009.04.008] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Revised: 03/30/2009] [Accepted: 04/25/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To critically review the best available studies evaluating the efficacy of lumbosacral transforaminal epidural steroid injections (TFESIs) in the treatment of radicular pain. DATA SOURCES MEDLINE, EMBASE, and the Cochrane database were searched for the period between 1950 and May 2008. Search terms included epidural steroid injection (ESI), transforaminal ESI, foraminal ESI, selective nerve root block, nerve root injection (NRI), selective NRI, periradicular infiltration, and periradicular injection. Randomized controlled trials (RCTs), published in English, which evaluated the efficacy of fluoroscopically guided TFESIs were reviewed. STUDY SELECTION Studies were analyzed with a quality checklist modeled after the 2001 CONSORT Statement: Revised Recommendations for Improving the Quality of Reports of Parallel-Group Randomized Trials. Nine studies were found to include a majority of these items. DATA EXTRACTION Data included study design, inclusion criteria, symptom duration, randomization protocol, blinding protocol, intervention, control, outcomes, follow-up, dropout, statistical analysis, and conclusions. DATA SYNTHESIS Each article was assigned a level of evidence: I (high-quality RCT) or II (RCT with <80% follow-up, no blinding or improper randomization). Studies were divided according to control, and overall evidence was graded as A (good), B (fair), C (conflicting/poor quality), or I (insufficient). CONCLUSIONS There is fair evidence supporting TFESIs as superior to placebo for treating radicular symptoms. There is good evidence that TFESIs should be used as a surgery-sparing intervention, and that TFESIs are superior to interlaminar ESIs (ILESIs) and caudal ESIs for radicular pain. In patients with subacute or chronic radicular symptoms, there is good evidence that a single TFESI has similar efficacy as a single transforaminal injection of bupivacaine or saline. Future studies should address the ideal number of injections. While more placebo-controlled trials are needed to conclusively define the role of TFESIs, current studies support their use in the treatment of lumbosacral radicular pain.
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Affiliation(s)
- Scott T Roberts
- Christiana Spine Center, MAP 2, Suite 3302, 4735 Ogletown-Stanton Road, Newark, DE 19713, USA.
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Akuthota V, Argoff C, Watters WC. Interpreting Reviews and Guidelines: The Case of Lumbar Epidural Steroid Injections. PM R 2009; 1:576-9. [DOI: 10.1016/j.pmrj.2009.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Accepted: 05/07/2009] [Indexed: 11/28/2022]
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Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976) 2009; 34:1078-93. [PMID: 19363456 DOI: 10.1097/brs.0b013e3181a103b1] [Citation(s) in RCA: 234] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To systematically assess benefits and harms of nonsurgical interventional therapies for low back and radicular pain. SUMMARY OF BACKGROUND DATA Although use of certain interventional therapies is common or increasing, there is also uncertainty or controversy about their efficacy. METHODS Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of local injections, botulinum toxin injection, prolotherapy, epidural steroid injection, facet joint injection, therapeutic medial branch block, sacroiliac joint injection, intradiscal steroid injection, chemonucleolysis, radiofrequency denervation, intradiscal electrothermal therapy, percutaneous intradiscal radiofrequency thermocoagulation, Coblation nucleoplasty, and spinal cord stimulation. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and by Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force. RESULTS For sciatica or prolapsed lumbar disc with radiculopathy, we found good evidence that chemonucleolysis is moderately superior to placebo injection but inferior to surgery, and fair evidence that epidural steroid injection is moderately effective for short-term (but not long-term) symptom relief. We found fair evidence that spinal cord stimulation is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. We found good or fair evidence that prolotherapy, facet joint injection, intradiscal steroid injection, and percutaneous intradiscal radiofrequency thermocoagulation are not effective. Insufficient evidence exists to reliably evaluate other interventional therapies. CONCLUSION Few nonsurgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials.
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Epidural steroid injections are useful for the treatment of low back pain and radicular symptoms: Con. Curr Pain Headache Rep 2009; 13:35-8. [DOI: 10.1007/s11916-009-0008-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Riboud C, Lerais JM, Sailley N, Kastler B. [Evaluation of the efficacy of CT-guided epidural and transforaminal steroid injections in patients with diskogenic radiculopathy]. ACTA ACUST UNITED AC 2008; 89:775-82. [PMID: 18641564 DOI: 10.1016/s0221-0363(08)73783-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE To evaluate the efficacy of CT-guided epidural and transforaminal steroid injections in patients with diskogenic radiculopathy. MATERIALS AND METHODS Seventy patients underwent CT guided injections after failure of medical management. Only patients with minimal degenerative changes and diskogenic monoradicular symptoms were treated. Only two patients with fibrosis were included. RESULTS 78.6% of patients experienced persistent symptomatic improvement. No difference was noted between lumbar segments and there was no more failures with epidural injections compared to transforaminal injections. Cervical disk herniations responded better than lumbar disk herniations. Good results were obtained in younger patients (M=46.25 years), symptomatic for 3-4 months or less, and with clear radicular symptoms and clinical neurological deficits (hypoesthesia, absent DTR) without motor deficit. No patient with severe spinal stenosis (S-) was included and the disk herniations were small (b1, b2, c1, c2 or d1, d2). Only a single injection was needed. Cortivazol provided superior results compared to dexamethasone. CONCLUSION CT-guided injections should be included in the therapeutic armamentarium after standard medical management, with cure as the goal.
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Affiliation(s)
- C Riboud
- Service de Radiologie, Hôpital d'Instruction des Armées Desgenettes, Lyon Armées, France
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Irnich D. Minimalinvasive Injektionstherapie beim radikulären Lumbalsyndrom. Schmerz 2008; 22:349-50, author reply 350-2. [DOI: 10.1007/s00482-008-0659-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Derby R, Lee SH, Date ES, Lee JH, Lee CH. Size and aggregation of corticosteroids used for epidural injections. PAIN MEDICINE 2008; 9:227-34. [PMID: 18298706 DOI: 10.1111/j.1526-4637.2007.00341.x] [Citation(s) in RCA: 145] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The purpose of this study was to document particulate size in commonly used corticosteroid preparations. Inadvertent injection of particulate corticosteroids into a vertebral or foraminal artery can cause brain and spinal cord embolic infarcts and the size of the particles could be directly related to the chance that a clinically significant infarct would occur. One might assume that corticosteroids with particles significantly smaller than red blood cells might be safer. DESIGN The following four types of corticosteroid preparations were used in various solutions and evaluated under light microscopy: dexamethasone sodium phosphate injection, triamcinolone acetonide injectable suspension, betamethasone sodium phosphate and betamethasone acetate injectable suspension, and methylprednisolone acetate injectable suspension. RESULTS Dexamethasone sodium phosphate particle size was approximately 10 times smaller than red blood cells and the particles did not appear to aggregate; even mixed with 1% lidocaine HCl solution and with contrast dye, the size of the particles were unchanged. Triamcinolone acetonide and betamethasone sodium phosphate showed variable sizes; some particles were larger than red blood cells, and aggregation of particles was evident. Methylprednisolone acetate showed uniformity in size and the majority were smaller than red blood cells which were not aggregated, but the particles were densely packed. CONCLUSIONS Compared with the particulate steroid solutions, dexamethasone sodium phosphate had particles that were significantly smaller than red blood cells, had the least tendency to aggregation, and had the lowest density. These characteristics should significantly reduce the risk of embolic infarcts or prevent them from occurring after intra-arterial injection. Until shown otherwise in clinical studies, interventionalists might consider using dexamethasone or another corticosteroid preparation with similar high solubility and negligible particle size when performing epidural injections.
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Affiliation(s)
- Richard Derby
- Spinal Diagnostics and Treatment Center, Daly City, California, USA
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El Abd O. Steroids in Spine Interventions. INTERVENTIONAL SPINE 2008:153-160. [DOI: 10.1016/b978-0-7216-2872-1.50018-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Gomez RS, Gusmão S, Silva JF, Bastos MP. Interlaminar epidural corticosteroid injection in the treatment of lumbosciatic pain: a retrospective analysis. ARQUIVOS DE NEURO-PSIQUIATRIA 2007; 65:1172-6. [DOI: 10.1590/s0004-282x2007000700015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2007] [Accepted: 09/28/2007] [Indexed: 11/22/2022]
Abstract
Lumbosciatica is a common condition which is associated with significant pain and disability. The aim of the present study was to examine the efficacy of interlaminar epidural corticosteroid infiltration in the treatment of lumbosciatic pain. We evaluated retrospectively sixty patients with lumbosciatic pain that a sequential interlaminar epidural administration of 40 mg methylprednisolone in 7 mL bupivacaine 0.25% was administered. Each patient was interviewed and asked about the pain according to visual analogue scale (VAS) and the level of disability according to World Health Organization previously of the epidural corticosteroid infiltration and, 1 and, 6 months after starting therapy. Independently of the initial VAS value, all patients decreased their pain score after one and six months of follow-up (p<0.05). However, only the patients with a low grade of disability showed an improvement after the treatment (p<0.05). No side effects were reported after epidural corticosteroid injections. In conclusion, interlaminar epidural corticosteroid injection in association with local anesthetic may be useful, at least for six months, as additional therapy of the conservative management of lumbosciatic pain.
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Pasqualucci A, Varrassi G, Braschi A, Peduto VA, Brunelli A, Marinangeli F, Gori F, Colò F, Paladini A, Mojoli F. Epidural local anesthetic plus corticosteroid for the treatment of cervical brachial radicular pain: single injection versus continuous infusion. Clin J Pain 2007; 23:551-7. [PMID: 17710003 DOI: 10.1097/ajp.0b013e318074c95c] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Efficacy of epidural local anesthetics plus steroids for the treatment of cervicobrachial pain is uncertain. METHODS A prospective study randomized 160 patients with cervicobrachial pain resistant to conventional therapy. Patients were divided into 4 groups on the basis of the time between pain onset and treatment initiation: group A, 40 patients with pain onset 15 to 30 days; group B, 40 patients with pain from 31 to 60 days; group C, 40 patients, 61 to 180 days; and group D, 40 patients with pain >180 days. Patients of each group were randomized to receive an epidural block with bupivacaine and methylprednisolone at intervals of 4 to 5 days (Single injection) or continuous epidural bupivacaine every 6, 12, or 24 hours plus methylprednisolone every 4 to 5 days (Continuos epidural). The maximum duration of treatment (9 blocks in Single injection, and 30 days in Continuos epidural) was dependent on achieving Pain Control (PC) > or =80% [PC is defined by this formulae: (100) (VAS(initial)-VAS(final))/VAS(initial)]. Follow-up at 1 month and 6 months compared PC and the number of pain-free hours of sleep. RESULTS One hundred forty-one patients completed the study. The 4 groups had similar characteristics. At the 1-month and 6-month follow-up analysis based on the time between pain onset and treatment initiation showed that patients of group D, who received the Continuous epidural treatment, had significantly greater PC and significantly more pain-free hours of sleep compared with similar patients in Single injection. CONCLUSIONS Therapy with continuous epidural local anesthetic and methylprednisolone provides better control of chronic cervicobrachial pain compared with Single injection. These results are discussed with respect to the possible mechanism of action of the drugs and may relate to the physiopathologic mechanisms associated with neuronal plasticity that result in chronic pain.
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Affiliation(s)
- Alberto Pasqualucci
- Department of Anesthesiology and Intensive Care, University of Perugia, Italy.
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Stafford MA, Peng P, Hill DA. Sciatica: a review of history, epidemiology, pathogenesis, and the role of epidural steroid injection in management. Br J Anaesth 2007; 99:461-73. [PMID: 17704089 DOI: 10.1093/bja/aem238] [Citation(s) in RCA: 174] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Radicular pain in the distribution of the sciatic nerve, resulting from herniation of one or more lumbar intervertebral discs, is a frequent and often debilitating event. The lifetime incidence of this condition is estimated to be between 13% and 40%. Fortunately, the majority of cases resolve spontaneously with simple analgesia and physiotherapy. However, the condition has the potential to become chronic and intractable, with major socio-economic implications. This review discusses the history, epidemiology, pathophysiology, and natural history of sciatica. A Medline search was performed to obtain the published literature on the sciatica, between 1966 and 2006. Hand searches of relevant journals were also performed. Epidemiological factors found to influence incidence of sciatica included increasing height, age, genetic predisposition, walking, jogging (if a previous history of sciatica), and particular physical occupations, including driving. The influence of herniated nucleus pulposus and the probable cytokine-mediated inflammatory response in lumbar and sacral nerve roots is discussed. An abnormal immune response and possible mechanical factors are also proposed as factors that may mediate pain. The ongoing issue of the role of epidural steroid injection in the treatment of this condition is also discussed, as well as potential hazards of this procedure and the direction that future research should take.
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Affiliation(s)
- M A Stafford
- Department of Anaesthesia, Ulster Hospital, Dundonald, Upper Newtownards Road, Belfast BT16 1RH, Ireland
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